Practical Approach to Microvascular Reconstruction of Significant Skull Base Defects

Background: Complex defects of the lateral and anterior skull base present challenges for the reconstructive surgeon. With the increasing use of microvascular free flaps and improved medical modeling technology, reconstruction of large complex defects can be approached with a practical algorithm. However, surgeons must be experienced with the full reconstructive ladder to balance the reconstruction with patient-oriented factors.

Methods: We reviewed and consolidated our experience and formulated a practical algorithm for reconstructing significant anterior and lateral skull base defects.

Results: A comprehensive algorithm was constructed based on critical analysis of each defect. We included a spectrum of reconstructions from optimal to safe and fast as the surgeon must balance each scenario with patient-oriented factors (health, prognosis, prior treatment) to achieve a safe, functional, and cosmetic wound. We divided the defects based on lateral and anterior skull base and skin versus no skin involvement. Lateral skull base defects are straightforward, and the workhorse for our group is the lateral arm fasciocutaneous free flap with or without a vascularized nerve graft for the facial nerve. Anterior defects are further subdivided based on the amount and site of bone involvement. Significant bone involvement increases the complexity, and we use medical modeling and preplanning for our cases. The scapular system remains the choice of our group for significant skin and bone defects of the anterior skull base.

Conclusions: We have constructed a practical algorithm to effectively reconstruct complex anterior and lateral skull base defects. A safe, effective, and functional reconstruction requires an experienced surgeon who is familiar with not only the complex anatomy of the region but also the reconstructive ladder. This must be balanced with patient-oriented factors to optimize reconstruction and achieve a safe, functional, and cosmetic wound.